Medicare is the federally funded health insurance program for those aged 65 and over, as well as younger people with certain health conditions. While many seniors lose their health insurance benefits when they retire, Medicare provides affordable coverage to help them control medical expenses as they age. In Wisconsin, approximately 1,276,565 people, or about a fifth of the state’s population, are eligible for Medicare. This is a 3% increase over the number of eligible state residents in 2022 compared to a 2.66% growth in eligible Medicare beneficiaries nationwide.
Original Medicare consists of Part A hospital insurance and Part B medical insurance, offering coverage for inpatient services like hospital stays and nursing home care, as well as routine checkups and certain medical equipment. While it helps seniors save on healthcare, beneficiaries are responsible for premiums, deductibles, co-pays, and coinsurance. Part A is usually free if the applicant or their spouse has paid Medicare taxes for at least 10 years, but otherwise costs $278 or $506 monthly, with a $1,600 deductible per hospital stay and additional co-pays for stays beyond 60 days. Part B typically has a monthly premium of $164.90, a $226 deductible, and 20% coinsurance, although costs can vary based on income.
In addition to Original Medicare, seniors in Wisconsin have access to Medicare Advantage Plans. These plans are available through private health insurance coverage and include all benefits in Parts A and B. In some cases, these plans have other benefits such as $0 deductibles and prescription drug, vision and dental insurance. About 52% of beneficiaries in Wisconsin, or 660,783 people, opt for this coverage over Original Medicare. By comparison, in 2022, only 48% of beneficiaries chose a private plan. Nationwide, 48% of Medicare beneficiaries chose this coverage, versus 45% in 2022.
This guide offers a comprehensive overview of available programs and resources to assist seniors in tailoring their coverage and making well-informed decisions about their health care.
Original Medicare offers basic coverage that every senior needs, but more people are exploring ways to add coverage that’s more suited to their needs. Wisconsinites have a few options for creating custom coverage and don’t need to depend solely on the normal Medicare program for their medical needs. They may find alternative plans through private insurance companies serving the state.
The Centers for Medicare & Medicaid Services oversees and administers Original Medicare in Wisconsin and the rest of the nation and sets rules about what the program must cover. Original Medicare features two parts, each with its own set of benefits. Part A pays for hospital stays, nursing home care, home health care and hospice, while Part B covers medical services such as primary care visits, emergency and nonemergency medical transportation and durable medical equipment. Neither part pays for prescription drug coverage, so seniors who want medications covered must purchase a separate Medicare Part D plan.
Who Should Consider Original Medicare
Original Medicare may be a good option for those who:
Medicare Advantage is an alternate way to receive Medicare benefits and is the preferred health care option for over half of Wisconsin’s Medicare beneficiaries. These plans aren’t serviced by CMS — they’re administered by private health insurance companies that comply with Medicare’s rules. Medicare Advantage Plans encompass all Original Medicare’s Part A and B benefits, and some plans also have prescription drug, dental and vision benefits. There are four types of Medicare Advantage Plans, including Health Maintenance Organizations, Preferred Provider Organizations, Pay-Fee-For-Service plans and Special Needs Plans, although not all plan types are available in all zip codes throughout Wisconsin.
Who Should Consider Medicare Advantage
Those who could benefit most from an Advantage plan include:
The Top 10 Medicare Advantage Plans in Wisconsin
There are 115 Medicare Advantage plans to choose from in Wisconsin in 2023. With so many choices, seniors may find the process of reviewing insurance companies daunting. This table reviews the top 10 Advantage providers (by enrollment across all plans for each provider) and the range of costs for each as of August 2023.
|Medicare Star Rating
|Monthly Cost Range
|$0 – $296
|$0 – $230
|$0 – $118
|PPO, HMO, PFFS
|Quartz Medicare Advantage
$0 – $162
|Anthem Blue Cross and Blue Shield
|$0 – $27
|Dean Advantage, Prevea360 Medicare Advantage
|$0 – $251
|$0 – $26
|Molina Healthcare of Wisconsin and Massachusetts
|$0 – $93
Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.
Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.
Who Should Consider Medicare Prescription Drug Coverage
Seniors who may benefit from prescription drug coverage include those who:
While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.
For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2023 page.
Who Should Consider Medicare Supplement Insurance
Good candidates for Medigap may be those who:
With so many choices for residents looking for affordable coverage that meets their individual needs, building the right plan can be time-consuming, confusing and frustrating. Fortunately, resources are available to help people review their coverage options, apply for benefits and understand their policies. These organizations offer assistance on both the federal and state levels and may provide counseling in person or virtually.
Wisconsinites can get plenty of information about their Medicare options from the Social Security Administration’s website, including enrollment periods, how to avoid paying penalties and what to do if they’ve lost their Medicare card. A section devoted to Medicare Advantage plans covers what makes them different from Original Medicare and how to choose the best plan. If seniors need to determine whether they qualify for financial assistance, the Social Security Administration offers a section on its website to apply for benefits.
The Wisconsin Department of Health Services offers several guides on Medicare coverage to help residents understand Medicare Advantage plans and Medigap policies. The website also provides a guide for residents who already have coverage, a brochure of approved Advantage plans in the state and information about Medicare prescription benefits.
The Wisconsin SHIP program works in coordination with the Wisconsin Department of Health Services to offer free counseling services for seniors looking to get the most out of their health care. SHIP counselors don’t represent any private insurance entity and can help residents review their choices, understand how benefits work, prepare their applications and apply for Medicaid and other financial aid.
Local Aging and Disability Resource Centers provide resources and support to seniors throughout Wisconsin who need assistance applying for benefits, obtaining medical care and remaining connected with their local communities. Residents can arrange meetings at their local office, over the phone or in the comfort of their own homes. Local Aging and Disability Resource Centers also provide support to family caregivers, such as respite care and educational resources.
The Senior Medicare Patrol program is a state-backed effort to help educate seniors about Medicare and Medicaid benefits while preventing abuse, exploitation and fraud. In addition to helping seniors apply for Medicare benefits, the Senior Medicare Patrol teaches residents how to protect their critical information, know when their information has been compromised and report scams and fraud.